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Newsweek, June 28, 2007

What Kills One Woman Every Minute of Every Day?; A. Heart attack; B. AIDS; C. Childbirth

By Barbara Kantrowitz

DATELINE: SAO PAULO Brazil -- Throughout most of human history childbirth has been the leading killer of women. That's still true today, even when modern medicine has the power to virtually eliminate maternal mortality. Somewhere in the world, one woman dies every minute of every day from causes related to pregnancy and birth--most often, uncontrolled bleeding and infection. The world's poorest women are the most vulnerable. In sub-Saharan Africa, the lifetime risk of maternal death is 1 in 16, compared with 1 in 2,800 in developed countries. Those who survive may still suffer. For every woman who dies during childbirth, it is estimated that another 30 are injured or become sick. According to the World Health Organization (WHO), more than 300 million women around the world currently live with illnesses brought about by pregnancy or birth. And women themselves are not the only victims. The children left behind are more likely to die simply because they are motherless.

Eliminating the disparity between rich and poor women requires rethinking the way society views childbirth. That has already happened in the industrialized world. Until the late 1880s, childbirth everywhere was considered the private domain of female family members and sometimes midwives. That meant that women were often at the mercy of nature. Many died because of high blood pressure when they were pregnant, which leads to a condition called eclampsia. Others bled to death after birth or died of an infection that spread throughout their bodies. A significant number lost their lives during labor, when their babies became stuck in the birth canal. Still others died from the consequences of primitive abortions when they tried to get rid of unwanted pregnancies.

But as women in Europe and North America began to lobby for more rights, maternal health care became a major public issue. Today, thanks to those efforts, the vast majority of women in the developed world have at least some access to skilled medical care during their pregnancies. Countries with the most widely available health services have the lowest mortality rates. In Sweden, for example, childbirth is so safe that only one woman dies for every 30,000 births, says Nancy Terreri, senior adviser for maternal and child health for UNICEF. (In this country, it's one in 2,500.) Sweden provides women with family planning, which cuts down on often dangerous teen pregnancies, as well as advanced care for high-risk births to older women, Terreri says.

In much of the rest of the world, childbirth is still very risky business. It's the top cause of death and disability for women of reproductive age--more than any other single health problem, according to the WHO. That's especially true in countries in the midst of war. In Afghanistan, for example, it is estimated one woman dies out of every seven women who give birth--which Terreri says is currently the highest rate in the world. "When a country is in conflict, they're not investing in those services," Terreri says. "It also makes reaching those services more difficult." In a refugee camp Terreri studied in Uganda, a single nurse treated thousands of women. Because of a government-imposed curfew, the nurse could be there only during the day. Although a well-equipped missionary hospital was a short distance away, the women had no way of getting there.

The situation is particularly tragic because solutions are simple and relatively inexpensive. The first step is education, teaching women themselves about the danger signs of pregnancy so they know when to seek help. Equally important is making skilled care available to women of all incomes. Dr. Luis B. Curet, an emeritus professor at the University of New Mexico, was in charge of a recent pilot program sponsored by the American College of Obstetricians and Gynecologists to reform obstetric care in four Central American countries. His group found that a few basic measures--providing antibiotics and medications to stop uterine contractions as well as training staff to deal with post-pregnancy complications--made a big difference. If you improve maternal mortality, he says, "there's a terrific beneficial effect on society as a whole."

Other helpful measures target specific diseases that threaten pregnant women. According to the WHO, 10,000 pregnant women and 200,000 infants die every year from malaria, which increases the chances of fatal anemia, stillbirth, low birth weight and neonatal death. All of these can be dramatically reduced by providing medication for malarial infection and insecticide-treated nets to stop the mosquitoes that carry the disease. Women with HIV also need specialized treatment. About 2.2 million women with HIV give birth each year. The virus raises the risk of complications such as anemia and postpartum bleeding. Their impaired immune systems also make these women more susceptible to diseases like malaria or tuberculosis. Understanding how pregnancy affects mental health is critical as well. Suicide caused by postpartum depression is a major issue, especially in countries with limited medical care. Giving birth may be the most natural thing in the world for a woman, but even Mother Nature needs a little help.

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